Pancreatic Neoplasms - Endocrine - Core/Disease Flashcards
What is the workup for PNETs?
- H&P
- Biochemical workup
- Localization imaging
What symptoms are associated with a nonfunctional PNET?
- Often asymptomatic
- Possible symptoms include:
- Abdominal pain
- Jaundice
- Anorexia
- Weight loss
What symptoms are associated with an insulinoma?
Classic Whipple Triad
- Hypoglycemia
- Neuroglycemia (diaphoresis, confusion)
- Resolution of symptoms with eating
What symptoms are associated with a gastrinoma?
- Abdominal pain
- Diarrhea (70%)
- Refractory PUD
What symptoms are associated with a glucagonoma?
The 4 Ds
- Diabetes
-
Dermatitis
- Necrolytic migratory erythema
- DVT
- Depression
What symptoms are associated with a somatostatinoma?
- Diabetes
- Cholelithiasis
- Malabsorption; steatorrhea
- Abdominal pain (39%), Jaundice (28%), GI Bleed (22%)
What symptoms are associated with a VIPoma?
Verner-Morrison Syndrome aka WDHA syndrome
-
Watery Diarrhea
- >5L/day
- Hypokalemia
- Achlorhydria
What is the biochemical workup for a nonfunctional PNET?
- Chromgranin A (>300 ng/mL)
OR
- Pancreatic Polypeptide (>200 pg/mL)
What is the biochemical workup for an insulinoma?
- Insulin:glucose during fasting
- >0.3 is diagnostic
- 72 hour fast - Gold Standard
- Glucose < 55
- Insulin 3+
- C-peptide > 0.2
- Proinsulin 5+
- Sulfonylureas neg
What is the biochemical workup for a gastrinoma?
- Fasing gastrin >1,000 is diagnostic
- If <1,000 perform secretin stim test
- Overnight fast
- IV secretin bolus (2 IU/kg)
- Gastrin lab obtained at 0, 2, 5, 10, 15 minutes after injection
- Gastrin increase >200 above baseline is diagnostic
Note: Gastrin levels are affected by PPI. Stop PPI prior to testing.
What is the biochemical workup for a glucagonoma?
Fasting glucagon level
-
> 1,000 is diagnostic
- Normal fasting level is <100
What is the biochemical workup for a somatostatinoma?
Fasting somatostatin level
- >160 is diagnostic
What is the biochemical workup for a VIPoma?
Serum VIP level
- 225-2,000 is diagnostic
How are PNETs localized preoperatively?
- CT/MRI
- EUS
- Better for small lesions
- Can perform FNA at same time
- Somatostatin receptor imaging (Octreoscan)
- Does not work for insulinomas (no somatostatin receptors)
- SPECT/CT
- Angiogram
- Portal venous sampling
- Ca stimulates insulin release
- Secretin stimlates gastrin release
Preoperative PNET localization was unsuccessful. What can be done in the OR to help localize the lesion?
- Intraoperative US
- Tactile sensation
- Duodenotomy for direct visualization
- Last resort for gatrinomas
